If Housing is Health Care, Should Insurers Pay?

A proposal from a Hawaii physician/legislator prompts the question: Is homelessness a medical condition?

When he treats a chronically homeless person in the emergency department, Joshua Green, M.D., wishes he could write the prescription most likely to improve the patient’s health: housing.

That’s why Green, a member of the Hawaii Legislature since 2004, introduced a bill that, if approved, would require all insurers, including Medicaid and Medicaid managed care plans, to cover “the treatment of homelessness.”

“I’m calling homelessness a health condition,” Green says. “That is a semantic move to get people’s attention, but it is true and I believe it. Homelessness is the ultimate social determinant of health.”

In a 2015 letter to the Internal Revenue Service, the American Hospital Association, the Catholic Health Association and the Association of American Medical Colleges argued for housing to be considered critical to health.

“ … numerous studies and research in the public health area have clearly established that ‘housing is health care,’” the groups wrote. A few months later, the IRS announced that investments in housing will be considered community benefit expenditures.

But Green’s proposal to require insurers to pay for housing is a radical idea — and one that is generating a lot of attention. From the Fox News Channel to The New York Times, media ran with the story and homeless advocates around the country paused to consider the possibility.

“There’s a desperation to find anything possible to put people into stable housing,” says Barbara DiPietro, senior director of policy for National Health Care for the Homeless Council.

Although she thinks Green’s idea won’t fly, DiPietro understands the math calculation behind the proposal. Less than 4 percent of Hawaii residents are using 60 percent — roughly $1.2 billion — of the state’s Medicaid budget every year, and many of those are homeless people.

“These are the individuals who are really struggling and getting hospital services in crisis because they don’t have a home, they don’t have a primary care physician and they don’t have a place to keep their medications,” Green says. “And our Medicaid budget is compromised.”

Research shows that placing homeless individuals and families in permanent housing, with supportive services, reduces their health care utilization significantly. The bottom line: The cost of housing homeless individuals and families would be more than offset by their lower health care costs.

The state’s budget for housing will never be sufficient to meet the need, Green says. Its Medicaid budget, however, would benefit every time it deployed dollars to put a chronically homeless person into permanent housing.

He thinks it will take legislators a while to warm to the idea, but he is encouraged by “very, very positive feedback” he has received. The Queen’s Health Systems, which provides more than 60 percent of care for homeless individuals seeking treatment, submitted written testimony in support of the legislation. In its testimony, the Hawaii Medical Association and the state’s Blue Cross and Blue Shield plan, expressed concern about a new mandate, but Green believes he will convince the insurer’s leaders that his idea will save money and improve people’s lives.

“I said, ‘You and I know by name these very people — the 300 highest-spend individuals who don’t get any better and need our help to get better,’” he says. “They absolutely agreed. They have been working on social determinants of health.”

Working at the national level, DiPietro is excited about the conversations that Green’s bill has sparked.

“But Medicaid should not pay for housing,” she says. “We need Medicaid to focus on health care services. We need housing dollars to focus on housing.”

She hopes the proposal will highlight the desperate need for housing units for homeless individuals and families.

“You can write prescriptions all day long, but we don’t have the units to put people in,” she says. “How would you follow through with filling that medical care plan? That’s what vexes all of us.”

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